There’s been a startling—but VERY welcome—development in the long-running MCPAR saga. On July 15, CMCS posted on its medicaid.gov the first three tranches of Managed Care Program Annual Reports (MCPARs) submitted by state Medicaid agencies for performance year 2023. The agency promises to post the remaining tranche for performance year 2023 in October, with quarterly updates to follow. With sincere apologies to Lerner and Loewe of My Fair Lady fame, they said that they would do it, would do it, would do it, they said that they would do it, and do it, they did!
Why the Broadway number? What is the big deal? And why should child health advocates care?
In most states, children and families have Medicaid coverage through managed care organizations (MCOs). As a practical matter, MCOs determine whether—and how well—Medicaid works for the people who are enrolled. State Medicaid agencies, which decide whether to contract with MCOs, and with which ones to contract, are responsible for monitoring their performance. Part of that monitoring duty is to report annually to CMS on the performance of each MCO; that report, the MCPAR, can give CMS some visibility into whether billions (with a “b”) of federal Medicaid matching funds flowing to MCOs each year are delivering the care to which enrollees are entitled. (MCPARs are specific to Medicaid; they do not apply to separate CHIP programs).
MCPARs are due to CMS no later than 180 days after the end of a state’s contract year. Some states contract with MCOs on a January 1 through December 31 basis; others on a July 1 through June 30 basis. Other states start their contracts on April 1, September 1, or October 1. As a result of the differing contract year periods, MCPARs are received by CMS in different tranches. The MCPARs posted by CMS last week reflect performance during contract years ending June 30, 2023, August 31, 2023 and September 30, 2023. (The MCPARs for the performance year ending December 31, 2023 were due to CMS in June but CMS does not expect to post them until the fall).
The “P” in MCPAR refers to “program,” which is the basis on which CMS has directed states to submit their reports. A managed care “program” is defined by a contract between the state and an MCO that has a specific set of capitation rate cells. For example, in this CMS posting there are three MCPARs from Georgia: one for Georgia Families (for children and families and pregnant women); one for Georgia Families 360 (for children and youth in foster care, adoption assistance, or juvenile justice); and one for Planning for Healthy Babies, Georgia’s section 1115 Family Planning demonstration.
Last week’s posting included 64 MCPARs submitted by 29 states (including the District of Columbia) plus Puerto Rico. The table below lists the 19 states that submitted MCPARs for MCO “programs” that cover Medicaid children and families generally (not those with enrollment limited to a particular subpopulation like children and youth in foster care or a particular set of services like behavioral health). These MCPARs, hyperlinked in the table, are now available for downloading and analysis.
All state Medicaid agencies contracting with MCOs are required to post the MCPARs they submit to CMS on their websites. (They are also required to make the MCPARs available to the beneficiary, provider, and other stakeholder representatives on the agency’s Medicaid Advisory Committee). In the past, state Medicaid agencies have generally not implemented this posting requirement, which CMS reaffirmed in the recent Managed Care Rule. As shown in the table, while state agency compliance does seem to be improving, less than half of the agencies (7) in this round of MCPAR reports still post them on their websites, which underscores the importance of CMS posting for public access to MCPAR information in those states.
So what’s in a MCPAR? CMS has developed a template for the types of information state agencies are required to report. The template includes, among other things, MCO-specific data on grievances and appeals by type of service, as well as external medical reviews, and state fair hearings; evaluation of individual MCO performance on quality measures for primary care access and preventive care, maternal and perinatal health, behavioral health, and other types of services; medical loss ratios (MLRs) for each MCO; and the sanctions or corrective action plans if any, imposed on each MCO and the reasons for each intervention.
Even if state agencies complete all the fields in the template, the MCPAR won’t provide anything close to a full picture of the performance of each MCO. It certainly does not move the needle much on MCO performance for children. For example, the template requests the average number of “individuals” enrolled in each MCO per month during the reporting year, but it does not request a breakdown by age (<21, 21-64, 65 and over) or by race and ethnicity. Similarly, the template requests the results of access and quality measures for each MCO in eight different domains, including child health and maternal and perinatal health. But the child health and maternity care measures that each state reports are likely to vary because CMS has not in the past required all states to report a standardized set of child health or maternity care measures. (Going forward, this should change as a result of new reporting requirements).
Nonetheless, the MCPAR is a start. When CMS posts the final tranche of MCPARs for the 2023 performance year in the fall, the MCPARs will allow comparison of individual MCO performance within states and between states. For example, it will be possible to compare the performance of a subsidiary of one of the Big Five national companies operating in one state with the performance of a subsidiary of the same Big Five company in another state (or the performance of a subsidiary of another Big Five company, if any, in the same state). Because of the limitations of the current MCPAR template, such comparisons will necessarily be incomplete, but they can serve as the basis for further inquiry.
Also, the MCPAR is not the only potential source of information about the performance of individual MCOs. Other sources include the Annual Technical Report prepared by each state’s External Quality Review Organization and posted on the websites of all states as well as MCO performance dashboards maintained by some states (for example, Oregon). And, in states with section 1115 waivers, the annual reports the state Medicaid agencies submit to CMS may also contain some useful data (we’ll say more about this in a future blog).
Despite the limitations of the MCPAR template in its current iteration, CMS’s decision to post state MCPARs, and to continue to do so going forward, is a transparency moment. MCOs and state Medicaid agencies now know that they are expected to provide standardized information about the performance of individual MCOs to CMS annually and that CMS will post the information for review by the public. This is a level of transparency without precedent in CMS’s administration of Medicaid managed care. Hopefully, with improvements in MCPAR content, it will lead to greater accountability of MCOs for their performance for children and families and other enrollees.
